You are asked to see a 5-year-old girl who has been unwell for several weeks and has had an intermittent fever. She has complained of swelling in her knees and some stiffness in her joints in the mornings. On examination she looks pale and tired with a red swollen left knee.
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(a) What else would you like to establish from the history?
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It is important to establish the duration of her symptoms and whether the pain and swelling has been continuous or recurrent. Has there been any history of trauma or any grazes that might have introduced infection? Has she lost any weight? Are there any other systemic symptoms that might make a malignancy more likely?
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(b) Which do you think is the most likely diagnosis?
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Juvenile idipathic arthritis. This often presents in an insidious way with hot painful joints which flare up and then settle spontaneously. Systemic symptoms (weight loss, lethargy and recurrent fever) are common.
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(c) What do these blood tests show?
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There is a normocytic anaemia with low reticulocyte count suggestive of chronic illness. The high CRP, high ESR and elevated platelets suggest an inflammatory process. The normal white cell count and absence of blast cells makes leukaemia unlikely.
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(d) What treatment would you advise?
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In the first instance non-steroidal anti-inflammatory drugs (e.g. ibuprofen) should be used. If the diagnosis of juvenile idiopathic arthritis (either systemic type or pauciarticular type) is confirmed, then disease-modifying drugs such as an immunosuppressant may be needed. Non-drug therapy with physiotherapy and sometimes splinting is advised.
